Optimizing pump-probe reflectivity measurements of ultrafast photoacoustics with modulated asynchronous optical sampling

Time-resolved optical pump-probe experiments enable the study of complex light-matter interactions on ultrafast timescales, provided that they reach sufficient sensitivity. For instance, with pump-induced ultrafast photoacoustics, probing the typically small changes in optical properties requires a high signal-to-noise ratio. Asynchronous optical sampling (ASOPS), using two separate pulsed lasers at slightly different repetition rates, can be effective at removing noise by averaging many rapidly acquired traces. However, the pump-probe delay scan with ASOPS is always as long as the pump pulse interval, which is inefficient if the delay-time range of interest is shorter. Here, we demonstrate two modified ASOPS schemes that optimize measurement efficiency by only scanning the range of interest. The modification based on frequency modulated ASOPS (MASOPS) is most efficient, especially in the presence of low-frequency flicker noise. We provide a proof-of-concept measurement of ultrafast photoacoustics in which we use MASOPS to scan a time delay of 1/20 of the pump pulse interval. The resulting noise floor is 20 times lower compared to conventional ASOPS, allowing for 20 times faster measurements. Furthermore, we show that by taking experimental noise characteristics into account, more traditional pump-probe methods can also be optimized.

Rationale and protocol for the efficacy, safety and tolerability of nangibotide in patients with septic shock (ASTONISH) phase IIb randomised controlled trial

INTRODUCTION

Septic shock is the subgroup of patients with sepsis, which presents as vasopressor dependence, an elevated blood lactate concentration and is associated with a mortality of at least 30%. Expression of the triggering receptor expressed on myeloid cells 1 (TREM-1) pathway, measured using a serum biomarker of pathway activation (soluble TREM-1, sTREM-1) has been associated with outcome in septic shock. Preclinical and early phase patient data suggest that therapeutic modulation of this pathway may improve survival.

METHODS AND ANALYSIS

Efficacy, Safety and Tolerability of Nangibotide in Patients with Septic Shock is a phase IIb randomised controlled trial that will take place in up to 50 centres in seven countries and recruit 450 patients with septic shock to receive either placebo or one of two doses of nangibotide, a novel regulator of the TREM-1 pathway. The primary outcome will be the impact of nangibotide therapy on the change in Sequential Organ Failure Assessment score from a baseline determined before initiation of study drug therapy. This will be assessed first in the patients with an elevated sTREM-1 level and then in the study population as a whole. In addition to safety, secondary outcomes of the study will include efficacy of nangibotide in relation to sTREM-1 levels in terms of organ function, mortality and long-term morbidity. This study will also facilitate the development of a novel platform for the measurement of sTREM-1 at the point of care.

ETHICS AND DISSEMINATION

The study has been approved by the responsible ethics committees/institutional review boards in all study countries: Belgium: Universitair Ziekenhuis Antwerpen, France: CPP Ile de France II, Denmark: Region Hovedstaden, Spain: ethics committee from Valld'Hebron Hospital, Barcelona, Finland: Tukija, Ireland: St. James' Hospital (SJH) / Tallaght University Hospital (TUH) Joint Research Ethics Committee, USA: Lifespan, Providence TRIAL REGISTRATION NUMBERS: EudraCT Number: 2018-004827-36 and NCT04055909.

Extreme ultraviolet light from a tin plasma driven by a 2-µm-wavelength laser

An experimental study of laser-produced plasmas is performed by irradiating a planar tin target by laser pulses, of 4.8 ns duration, produced from a KTP-based 2-µm-wavelength master oscillator power amplifier. Comparative spectroscopic investigations are performed for plasmas driven by 1-µm- and 2-µm-wavelength pulsed lasers, over a wide range of laser intensities spanning 0.5 - 5 × 10¹¹ W/cm ². Similar extreme ultraviolet (EUV) spectra in the 5.5-25.5 nm wavelength range and underlying plasma ionicities are obtained when the intensity ratio is kept fixed at I_1µm/I_2µm = 2.4(7). Crucially, the conversion efficiency (CE) of 2-µm-laser energy into radiation within a 2% bandwidth centered at 13.5 nm relevant for industrial applications is found to be a factor of two larger, at a 60 degree observation angle, than in the case of the denser 1-µm-laser-driven plasma. Our findings regarding the scaling of the optimum laser intensity for efficient EUV generation and CE with drive laser wavelength are extended to other laser wavelengths using available literature data.

Phase retrieval algorithms for lensless imaging using diffractive shearing interferometry

Diffractive shearing interferometry (DSI) is a method that has recently been developed to perform lensless imaging using extreme ultraviolet radiation generated by high-harmonic generation. In this paper, we investigate the uniqueness of the DSI solution and the requirements for the support constraint size. We find that there can be multiple solutions to the DSI problem that consist of displaced copies of the actual object. These alternative solutions can be eliminated by enforcing a sufficiently tight support constraint, or by introducing additional synthetic constraints. We furthermore propose a new DSI algorithm inspired by the analogy with coherent diffractive imaging (CDI) algorithms: the original DSI algorithm is in a way analogous to the hybrid input-output algorithm as used in CDI, and we propose a new algorithm that is more analogous to the error reduction algorithm as used in CDI. We find that the newly proposed algorithm is suitable for final refinement of the reconstruction.

Nangibotide in patients with septic shock: a Phase 2a randomized controlled clinical trial

PURPOSE

Nangibotide is a specific TREM-1 inhibitor that tempered deleterious host-pathogens interactions, restored vascular function, and improved survival, in animal septic shock models. This study evaluated the safety and pharmacokinetics of nangibotide and its effects on clinical and pharmacodynamic parameters in septic shock patients.

METHODS

This was a multicenter randomized, double-blind, two-stage study. Patients received either continuous infusion of nangibotide (0.3, 1.0, or 3.0 mg/kg/h) or placebo. Treatment began < 24 h after shock onset and continued for up to 5 days. Safety primary outcomes were adverse events (AEs), whether serious or not, and death. Exploratory endpoints evaluated nangibotide effects on pharmacodynamics, organ function, and mortality, and were analyzed according to baseline sTREM-1 concentrations.

RESULTS

Forty-nine patients were randomized. All treatment emergent AEs (TEAEs) were collected until Day 28. No significant differences were observed in TEAEs between treatment groups. No drug withdrawal linked to TEAE nor appearance of anti-drug antibodies were reported. Nangibotide pharmacokinetics appeared to be dose-proportional and clearance was dose-independent. Nangibotide did not significantly affect pharmacodynamic markers. Decrease in SOFA score LS mean change (± SE) from baseline to Day 5 in pooled nangibotide groups versus placebo was - 0.7 (± 0.85) in the randomized population and - 1.5 (± 1.12) in patients with high baseline plasma sTREM-1 concentrations (non-significant). This pattern was similar to organ support end points.

CONCLUSION

No significant increases in TEAEs were detected in nangibotide-treated patients versus placebo. These results encourage further evaluation of nangibotide and further exploration of plasma sTREM-1 concentrations as a predictive efficacy biomarker.

Prominent radiative contributions from multiply-excited states in laser-produced tin plasma for nanolithography

Extreme ultraviolet (EUV) lithography is currently entering high-volume manufacturing to enable the continued miniaturization of semiconductor devices. The required EUV light, at 13.5 nm wavelength, is produced in a hot and dense laser-driven tin plasma. The atomic origins of this light are demonstrably poorly understood. Here we calculate detailed tin opacity spectra using the Los Alamos atomic physics suite ATOMIC and validate these calculations with experimental comparisons. Our key finding is that EUV light largely originates from transitions between multiply-excited states, and not from the singly-excited states decaying to the ground state as is the current paradigm. Moreover, we find that transitions between these multiply-excited states also contribute in the same narrow window around 13.5 nm as those originating from singly-excited states, and this striking property holds over a wide range of charge states. We thus reveal the doubly magic behavior of tin and the origins of the EUV light.

Extreme ultraviolet (EUV) light is entering use in nanolithography. Here the authors discuss experimental and theoretical results about the prominent role of multiply-excited states in highly charged tin ions in the mechanism of EUV light emission from laser-produced plasma.

Extreme ultraviolet lensless imaging without object support through rotational diversity in diffractive shearing interferometry

We report on a method that allows microscopic image reconstruction from extreme-ultraviolet diffraction patterns without the need for object support constraints or other prior knowledge about the object structure. This is achieved by introducing additional diversity through rotation of an object in a rotationally asymmetric probe beam, produced by the spatial interference between two phase-coherent high-harmonic beams. With this rotational diffractive shearing interferometry method, we demonstrate robust image reconstruction of microscopic objects at wavelengths around 30 nm, using images recorded at only three to five different object rotations.

Broadband extreme ultraviolet dispersion measurements using a high-harmonic source

We demonstrate direct dispersion measurements of various thin films at extreme ultraviolet (EUV) wavelengths, using a table-top laser-driven high-harmonic generation (HHG) source. In this method, spatially separated identical EUV pulses are generated through HHG with a pair of phase-locked infrared pulses. The EUV pulses are re-imaged to a sample plane using a single toroidal mirror, such that one pulse illuminates the target thin film, while the other pulse passes through a reference aperture. By comparing the EUV interference with and without a sample, we are able to extract the dispersion properties of the sample, integrated over the full film thickness. We have measured thin films of titanium, nickel, copper, and silicon nitride, demonstrating that this technique can be applied to a wide range of materials, only requiring a film thin, enough for sufficient EUV transmission.

Establishing a model of primary bovine hepatocytes with responsive growth hormone receptor expression

The liver becomes resistant to growth hormone before parturition in dairy cows (uncoupling of the somatotropic axis). However, the mechanism of growth hormone insensitivity has not been fully described. The aim of the present study was to improve a previous model of adult bovine hepatocytes in a sandwich culture system to ensure growth hormone receptor (GHR) expression. First, we modified the protocol for hepatocyte retrieval and tested the effect of short (18 min) and long (up to 30 min) warm ischemia on hepatocyte viability. Second, we used medium additives that affect GHR expression in vivo-insulin (INS), dexamethasone (DEX), both (INS+DEX), or no hormone additives (CTRL)-to ensure the functionality of hepatocytes, as measured by lactate dehydrogenase activity and urea concentration in the medium. We also used reverse transcriptase PCR of hepatocytes to evaluate expression of albumin (ALB), hepatocyte nuclear factor 4α (HNF4A), nuclear factor-κ-B-inhibitor α (NFKBIA), cytosolic phosphoenolpyruvate carboxykinase (PCK1), and vimentin (VIM) mRNA. Moreover, we analyzed the expression of GHRtot (GHR), GHR1A, insulin-like growth factor-1 (IGF1), and IGF binding protein-2 (IGFBP2) in response to exposure to media with the different compositions. Modification of the protocol (changes in rinsing and perfusion times, buffer composition, and the volume and standardization of collagenase) led to increased cell counts and cell viability. Short warm ischemia with the modified protocol significantly increased cell count (4.7 × 10⁷ ± 1.9 × 10⁷ vs. 3.5 × 10⁶ ± 1.5 × 10⁶ vital cells/g of liver) and viability (79.1 ± 8.4 vs. 37.1 ± 8.9%). Therefore, we gathered hepatocytes from the liver after short warm ischemia with the modified protocol. For these hepatocytes, lactate dehydrogenase activity was lower in media with INS and with DEX than in media with INS+DEX or CTRL; urea concentrations were highest at d 4 for INS+DEX. As well, HNF4A and ALB were more highly expressed in hepatocytes cultured with INS and INS+DEX than in those cultured with DEX or CTRL, and the substitution of DEX suppressed VIM and NFKBIA expression but increased PCK1 expression. The expression of GHR, GHR1A, and IGF1 was suppressed by dexamethasone (DEX and INS+DEX), whereas INS distinctly increased GHR, GHR1A, and IGF1 mRNA expression. Hepatocytes in a sandwich culture showed influenceable GHR expression; this study provides a model that can be used in studies examining factors that influence the expression and signal transduction of GHR in dairy cows.

Detection of periodic structures through opaque metal layers by optical measurements of ultrafast electron dynamics

We report on femtosecond optical pump-probe measurements of ultrafast electron dynamics to detect the presence of gratings buried underneath optically opaque gold layers. Electron energy diffusion and cooling are found to be strongly affected by the presence and type of metal buried below the gold layer. As a result, the spatially periodic buried grating is encoded on the electron temperature near the top surface, leading to a spatially periodic modulation of the optical properties near the gold surface from which a delayed probe pulse can be diffracted. Our measurements show that these effects may be useful for optical detection and alignment applications in semiconductor device manufacturing.

A first-in-man safety and pharmacokinetics study of nangibotide, a new modulator of innate immune response through TREM-1 receptor inhibition

AIMS

The peptide nangibotide is the first clinical-stage agent targeting the immunoreceptor TREM-1 (triggering receptor expressed on myeloid cells-1) and is being investigated as a novel therapy for acute inflammatory disorders such as septic shock. This first-in-man, randomized, double-blind, ascending dose, placebo-controlled Phase I study evaluated the safety, tolerability and pharmacokinetics of nangibotide.

METHODS

Twenty-seven healthy subjects (aged 18-45 years) were randomized into eight groups. Nangibotide was administered as a single continuous intravenous infusion. The first two groups received a single i.v. dose of 1 and 10 mg, respectively, over 15 min. Subsequent groups were randomized in a product : placebo ratio of 3:1 at doses ranging from 0.03 to 6 mg kg^-1  h^-1 over 7 h 45 min, preceded by a 15-minute loading dose of up to 5 mg kg^-1 .

RESULTS

Nangibotide was safe and well tolerated up to the highest dose tested. There were only few adverse events and they were mild in severity and considered unrelated to treatment. Nangibotide displayed dose-proportional PK properties, with a clearance of 6.6 l kg^-1  h^-1 for a subject of 70 kg and a 3 min effective half-life, which are compatible with extensive enzymatic metabolism in blood. Central and peripheral volumes of distribution were 16.7 l and 15.9 l respectively, indicating limited distribution of the drug mainly in blood and interstitial fluid. No circulating anti-drug antibodies were detectable up to 28 days after administration.

CONCLUSIONS

The novel immunomodulator nangibotide displayed favourable safety and PK profiles at all doses, including expected pharmacologically active doses, and warrants further clinical development.

Die Permeabilität des Hämostasethrombus gegenüber Plasma

1. Die Permeabilität des Hämostasepfropfes an einem verletzten muskulären Blutgefäß gegenüber Plasma wurde vitalmikroskopisch durch Fluoreszenzmarkierung des Plasmas untersucht. Das Beobachtungsobjekt waren die Mesenterialgefäße der weißen Ratte. Die Fluorochromierung erfolgte mit Brillantsulfoflavin oder Fluoresceinisothiocyanat-Proteinkonjugat.

2. Der suffiziente hämostatische Plättchenthrombus wird zu gleicher Zeit für Erythrozyten und für Plasma impermeabel.

3. Der Hämostasepfropf wird von Plasma durchtränkt, besonders in der Phase seines Wachstums, weniger auch nach seiner Konsolidierung.

4. In der Umgebung der Verletzung ist die Permeabilität der betroffenen muskulären Blutgefäß wände gegenüber Plasma gesteigert. Benachbarte unverletzte Gefäße können ebenfalls eine umschriebene, wahrscheinlich humoral verursachte Permeabilitätssteigerung zeigen.

5. Zwischen dem in vitro mit Protein konjugierten Fluoresceinisothiocyanat und dem intravasal fluorochromierenden Brillantsulfoflavin ergaben sich keine sicheren Unterschiede im Permeabilitätsverhalten der Fluoreszenz.

Die Hämostaseinsuffizienz bei Thrombinblockade durch Hirudin

1. Der Einfluß einer Blockade der spezifischen Fermentwirkung des Thrombins durch intravenöse Hirudininjektion auf die Hämostase größerer muskulärer Blutgefäße des Rattenmesenteriums wurde vitalmikroskopisch untersucht.

2. Nach 1000 AT-E. Hirudin/100 g Körpergewicht kommt es zu einer signifikanten Hämostaseinsuffizienz mit Verlängerung der Blutungszeit an Arterien und Venen.

3. Der Hämostasedefekt beruht auf der mangelhaften Festigkeit des hämo-statischen Plättchenpfropfes, zum Teil auch auf dem Fehlen einer sichtbaren Plättchenagglomeration an der Gefäßwunde.

4. Die lokale Konstriktion des verletzten Blutgefäßes wird durch Hirudin nicht unterdrückt. Dagegen fehlt nach Venenverletzung die kollaterale umschriebene Vasokonstriktion der unverletzten Nachbargefäße.

5. An blutenden Venen macht sich eine Thrombinblockade stärker bemerkbar als an Arterien. Sie tritt an ihnen schon nach einer Hirudindosis von 500 AT-E./ 100 g in Erscheinung.

6. Auf Grund dieser Befunde beruhen die folgenden Vorgänge während der Hämostase größerer muskulärer Blutgefäße auf einer spezifischen Thrombin-wirkung: a) das Wachstum und die mechanische Resistenz des Plättchenwundthrombus, b) wahrscheinlich auch die Anheftung der Plättchen an der Gefäßwunde, c) die kollaterale Vasokonstriktion benachbarter größerer unverletzter Blutgefäße.

Diffractive shear interferometry for extreme ultraviolet high-resolution lensless imaging

We demonstrate a novel imaging approach and associated reconstruction algorithm for far-field coherent diffractive imaging, based on the measurement of a pair of laterally sheared diffraction patterns. The differential phase profile retrieved from such a measurement leads to improved reconstruction accuracy, increased robustness against noise, and faster convergence compared to traditional coherent diffractive imaging methods. We measure laterally sheared diffraction patterns using Fourier-transform spectroscopy with two phase-locked pulse pairs from a high-harmonic source. Using this approach, we demonstrate spectrally resolved imaging at extreme ultraviolet wavelengths between 28 and 35 nm.

Spectrally resolved single-shot wavefront sensing of broadband high-harmonic sources

Wavefront sensors are an important tool to characterize coherent beams of extreme ultraviolet radiation. However, conventional Hartmann-type sensors do not allow for independent wavefront characterization of different spectral components that may be present in a beam, which limits their applicability for intrinsically broadband high-harmonic generation (HHG) sources. Here we introduce a wavefront sensor that measures the wavefronts of all the harmonics in a HHG beam in a single camera exposure. By replacing the mask apertures with transmission gratings at different orientations, we simultaneously detect harmonic wavefronts and spectra, and obtain sensitivity to spatiotemporal structure such as pulse front tilt as well. We demonstrate the capabilities of the sensor through a parallel measurement of the wavefronts of 9 harmonics in a wavelength range between 25 and 49 nm, with up to λ/32 precision.

High-energy Nd:YAG laser system with arbitrary sub-nanosecond pulse shaping capability

We report on a laser system capable of generating high-energy (>270  mJ) temporally shaped pulses at 1064 nm with 0.43-ns shaping resolution. The pulses are generated by modulation of a continuous-wave seed laser and subsequent amplification by a dual-stage grazing-incidence Nd:YVO4 "bounce" amplifier and a Nd:YAG power amplifier (all quasi-continuous diode-pumped). The system produces pulses with a high-quality top-hat spatial beam profile with up to 0.6 GW of peak power and 44 W of average power, a power stability of 0.22% rms, and fully programmable complex temporal shapes.

Safety and Efficacy of a Novel Microbial Lipase in Patients with Exocrine Pancreatic Insufficiency due to Cystic Fibrosis: A Randomized Controlled Clinical Trial

OBJECTIVE

To evaluate the safety and efficacy of a novel microbial lipase (NM-BL) in a liquid formulation for the treatment of exocrine pancreatic insufficiency (EPI) in patients with cystic fibrosis (CF) in a phase IIa proof-of-concept study.

STUDY DESIGN

We conducted a double-blind, randomized, placebo controlled crossover study in patients with cystic fibrosis and exocrine pancreatic insufficiency. Adolescent and adult patients with CF were randomized to receive NM-BL or placebo for 1 week as replacement for their usual pancreatic enzyme formulation. They were subsequently crossed-over to the alternate study treatment. The coefficient of fat absorption was evaluated as the primary endpoint. Symptoms and adverse events were evaluated as secondary endpoints.

RESULTS

A total of 35 patients were randomized into the study and 22 patients completed both treatment periods. During treatment with NM-BL, the coefficient of fat absorption was significantly greater (72.7%) compared with placebo (53.8%) with a difference between groups of 18.8% (P < .001). Subjective assessment of stool fat and stool consistency also improved under treatment with NM-BL. Adverse events were mostly gastrointestinal in nature and were more common in the group receiving NM-BL.

CONCLUSIONS

Currently available pancreatic enzyme products are limited because of the lack of liquid formulations and being largely porcine based. The novel microbial lipase NM-BL was safe and effective in this short term trial. The trial provided clinical proof-of-concept for this novel microbial lipase as a treatment for EPI in CF. A larger phase 2 dose ranging trial is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01710644.

Comparison of treatment outcomes for superficial digital flexor tendonitis in National Hunt racehorses

Superficial digital flexor (SDF) tendonitis is a common injury in Thoroughbred racehorses. Injuries require prolonged rehabilitation, with unpredictable outcomes and a high incidence of re-injury. This observational case-control study aimed to compare race outcomes after commonly advocated treatments for tendon healing. Clinical and racing records were evaluated for 127 National Hunt racehorses treated between 2007 and 2011 for an SDF tendon injury. Two age- and sex-matched control horses were selected for each case horse to analyse the effect on post-injury racing outcomes of pre-injury data, lesion severity and treatment group [controlled exercise alone, bar firing, intralesional platelet-rich plasma (PRP), tendon splitting, tendon splitting combined with bar firing]. Control horses raced more often than case horses, with higher maximum racing post rating (RPRmax) and longer racing distances. Pre-injury racing performance was not associated with treatment group. Rate of return to racing was not associated with lesion severity or treatment group. Number of races, total distance raced post-injury and RPRmax were not associated with lesion severity or treatment group. Controlled exercise alone offered similar post-injury racing outcomes in National Hunt racehorses with SDF tendonitis to the other treatment options examined. Bar firing, either alone or in conjunction with tendon splitting, provided no additional benefit in rate of return to racing and race performance.

Estimating the contribution of everolimus to immunosuppressive efficacy when combined with tacrolimus in liver transplantation: a model-based approach

Determining the efficacy contribution of an investigational drug as part of a novel combination regimen that also includes a previously untested dose of a standard treatment is challenging, particularly when "placebo control" data (combination regimen minus the investigational drug) is not available for comparison. This situation was encountered in a phase III trial that tested the combination of the investigational drug everolimus with a dose of tacrolimus lower than used in standard liver transplantation therapy. The challenge was addressed by predicting the efficacy of the placebo control from the study data using a pharmacometric-based exposure-response analysis, selected to account for features specific to the transplant setting: systematic change in drug exposure over time and sparse pharmacokinetic sampling. The efficacy contribution of everolimus was then demonstrated by comparing this prediction to the efficacy of the combination regimen. This pharmacometrics-based approach may contribute to characterization of therapeutic agents in real-world settings.

Illustrating the formation of metal nanoparticles with a growth concept based on colloidal stability

The growth process of various colloidal metal nanoparticles is illustrated using a novel concept based on colloidal stability.

Everolimus with reduced tacrolimus improves renal function in de novo liver transplant recipients: a randomized controlled trial

In a prospective, multicenter, open-label study, de novo liver transplant patients were randomized at day 30±5 to (i) everolimus initiation with tacrolimus elimination (TAC Elimination) (ii) everolimus initiation with reduced-exposure tacrolimus (EVR+Reduced TAC) or (iii) standard-exposure tacrolimus (TAC Control). Randomization to TAC Elimination was terminated prematurely due to a higher rate of treated biopsy-proven acute rejection (tBPAR). EVR+Reduced TAC was noninferior to TAC Control for the primary efficacy endpoint (tBPAR, graft loss or death at 12 months posttransplantation): 6.7% versus 9.7% (-3.0%; 95% CI -8.7, 2.6%; p<0.001 for noninferiority [12% margin]). tBPAR occurred in 2.9% of EVR+Reduced TAC patients versus 7.0% of TAC Controls (p = 0.035). The change in adjusted estimated GFR from randomization to month 12 was superior with EVR+Reduced TAC versus TAC Control (difference 8.50 mL/min/1.73 m(2) , 97.5% CI 3.74, 13.27 mL/min/1.73 m(2) , p<0.001 for superiority). Drug discontinuation for adverse events occurred in 25.7% of EVR+Reduced TAC and 14.1% of TAC Controls (relative risk 1.82, 95% CI 1.25, 2.66). Relative risk of serious infections between the EVR+Reduced TAC group versus TAC Controls was 1.76 (95% CI 1.03, 3.00). Everolimus facilitates early tacrolimus minimization with comparable efficacy and superior renal function, compared to a standard tacrolimus exposure regimen 12 months after liver transplantation.

Everolimus is associated with a reduced incidence of cytomegalovirus infection following de novo cardiac transplantation

BACKGROUND

Cytomegalovirus (CMV) causes several complications following cardiac transplantation including cardiac allograft vasculopathy. Previous studies suggested that immunosuppressive treatment based on everolimus might reduce CMV infection. Aiming to better characterize the action of everolimus on CMV and its interplay with patient/recipient serology and anti-CMV prophylaxis, we analyzed data from 3 large randomized studies comparing various everolimus regimens with azathioprine (AZA)- and mycophenolate mofetil (MMF)-based regimens.

METHODS

CMV data were analyzed from 1009 patients in 3 trials of de novo cardiac transplant recipients who were randomized to everolimus 1.5 mg/day, everolimus 3 mg/day, or AZA 1-3 mg/kg/day, plus standard-dose (SD) cyclosporine (CsA; study B253, n = 634); everolimus 1.5 mg/day plus SD- or reduced-dose (RD)-CsA (study A2403, n = 199); and everolimus 1.5 mg/day plus RD-CsA or MMF plus SD-CsA (study A2411, n = 176).

RESULTS

In study B253, patients allocated to everolimus experienced almost a 70% reduction in odds of experiencing CMV infection compared with AZA (P < 0.001). In study A2403, CMV infection was low in both everolimus arms, irrespective of CsA dosing, and in study A2411, patients allocated to everolimus experienced an 80% reduction in odds of experiencing CMV infection, compared with MMF (P < 0.001). CMV syndrome/disease was rare and less frequent in everolimus-treated patients. Subgroup analyses showed that the benefit everolimus provides, in terms of CMV events, is retained in CMV-naïve recipients and is independent of anti-CMV prophylaxis or preemptive approaches.

CONCLUSIONS

Everolimus is associated with a lower incidence of CMV infection compared with AZA and MMF, which combined with its immunosuppressive efficacy and antiproliferative effects may positively impact long-term outcomes.

Low-dose prednisone chronotherapy for rheumatoid arthritis: a randomised clinical trial (CAPRA-2)

OBJECTIVE

To assess the efficacy and safety of low-dose prednisone chronotherapy using a new modified-release (MR) formulation for the treatment of rheumatoid arthritis (RA).

METHODS

In this 12-week, double-blind, placebo-controlled study, patients with active RA (n=350) were randomised 2:1 to receive MR prednisone 5 mg or placebo once daily in the evening in addition to their existing RA disease-modifying antirheumatic drug (DMARD) treatment. The primary end point was the percentage of patients achieving a 20% improvement in RA signs and symptoms according to American College of Rheumatology criteria (ie, an ACR20 response) at week 12. Changes in morning pain, duration of morning stiffness, 28-joint Disease Activity Score and health-related quality of life were also assessed.

RESULTS

MR prednisone plus DMARD treatment produced higher response rates for ACR20 (48% vs 29%, p<0.001) and ACR50 (22% vs 10%, p<0.006) and a greater median relative reduction from baseline in morning stiffness (55% vs 35%, p<0.002) at week 12 than placebo plus DMARD treatment. Significantly greater reductions in severity of RA (Disease Activity Score 28) (p<0.001) and fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue score) (p=0.003) as well as a greater improvement in physical function (36-item Short-Form Health Survey score) (p<0.001) were seen at week 12 for MR prednisone versus placebo. The incidence of adverse events was similar for MR prednisone (43%) and placebo (49%).

CONCLUSION

Low-dose MR prednisone added to existing DMARD treatment produced rapid and relevant improvements in RA signs and symptoms. CLINICALTRIALS.GOV, NUMBER: NCT00650078.

Sotrastaurin, a novel small molecule inhibiting protein-kinase C: randomized phase II study in renal transplant recipients

Sotrastaurin, a selective protein-kinase-C inhibitor, blocks early T-cell activation through a calcineurin-independent mechanism. In this study, de novo renal transplant recipients with immediate graft function were randomized 1:2 to tacrolimus (control, n = 44) or sotrastaurin (300 mg b.i.d.; n = 81). All patients received basiliximab, mycophenolic acid (MPA) and steroids. The primary endpoint was the composite of treated biopsy-proven acute rejection (BPAR), graft loss, death or lost to follow-up at month 3. The main safety assessment was estimated glomerular filtration rate (eGFR); modification of diet in renal disease (MDRD) at month 3. Composite efficacy failure at month 3 was higher for the sotrastaurin versus control regimen (25.7% vs. 4.5%, p = 0.001), driven by higher BPAR rates (23.6% vs. 4.5%, p = 0.003), which led to early study termination. Median (± standard deviation [SD]) eGFR was higher for sotrastaurin versus control at all timepoints from day 7 (month 3: 59.0 ± 22.3 vs. 49.5 ± 17.7 mL/min/1.73 m(2) , p = 0.006). The most common adverse events were gastrointestinal disorders (control: 63.6%; sotrastaurin: 88.9%) which led to study-medication discontinuation in two sotrastaurin patients. This study demonstrated a lower degree of efficacy but better renal function with the calcineurin-inhibitor-free regimen of sotrastaurin+MPA versus the tacrolimus-based control. Ongoing studies are evaluating alternative sotrastaurin regimens.